- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.10 / $1,279.06 / $15,467.00
| Professional | | $233.10 | $1,279.06 | $15,467.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.42 / $375.42 / $375.42
| Facility | | $375.42 | $375.42 | $375.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.64 / $562.97 / $4,460.09
| Professional | | $267.64 | $562.97 | $4,460.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.91 / $505.63 / $3,609.89
| Facility | | $230.91 | $505.63 | $3,609.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.78 / $2,301.02 / $6,614.08
| Professional | | $336.78 | $2,301.02 | $6,614.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.36 / $4,492.87 / $5,616.11
| Professional | | $803.36 | $4,492.87 | $5,616.11 |